Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator Tyrone "Aaron" Powell.

The facility is licensed for a maximum capacity of 6 ambulatory clients. During today’s visit, the facility had a census of 5 ambulatory clients. The Administrator for the facility is Tyrone Powell and their certificate was valid and current.

During today’s visit, LPA toured the facility and inspected each room of the facility, including client rooms, bathrooms for client and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. LPA observed dry wall and wooden boards, vehicle tires, and other construction supplies and clutter stored in the facility backyard and are accessible to clients. Per Administrator, the clients do not access the backyard, however, a client room exits directly into the backyard. The facility’s water temperature was measured at 119.8 degrees Fahrenheit in a common bathroom. The facility’s internal temperature was measured at 74 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Tyrone "Aaron" Powell, no firearms or weapons are stored on the premises. LPA also observed locked storage for client medications and client and staff files. Client medications are stored in their original container and labelled. Review of clients' Medication Administration Record (MAR) log revealed that the MAR log for 3 of 5 clients are not kept up to date with currently prescribed medications. Additionally, medications that have been discontinued are still being signed as given to clients. Review of client medications and interviews with staff did not reveal any evidence that medications that do not have a current doctor's order or that have been discontinued have been given to clients.